The amount of literature on the subject of preoperative medication can be overwhelming. This may be because there is no “ideal” medication available that is free from unwanted side effects. When deciding whether to administer medication to a child before surgery, one should consider, first, whether that child is a candidate for such medication, and, secondly, which medication would be most appropriate for that child. There is no perfect formula for this, but one general rule is to consider both the comfort and the safety of the child when making these choices. This is yet another situation where much can be learned from observing the senior pediatric anesthesia providers. Experienced pediatric anesthesiologists start like the rest of us—with the general rule that both the safety and the comfort of the child must be considered. But they then know how to use the available agents to take an anxious, upset child and transition smoothly to an anesthetized patient.

When choosing whether to give medications preoperatively to a child, it is imperative to consider the consequences of doing so. The advantages of administering medication before surgery are well described and include the dissipation of preoperative anxiety, for both the child and the parent. Preoperative medication can facilitate separation from the parents and can smooth induction in the operating room. Of course, there are also disadvantages to giving medication to children preoperatively, which can include anything from inconvenient side effects, such as prolonged recovery, to dangerous side effects, like oxygen desaturation and loss of airway control.

The perfect preoperative medication would have the following characteristics:

For outpatient pediatric patients about to have anesthesia, a medication that does not require intravenous (IV) administration would be most useful.
One of a child’s worst fears associated with coming to the hospital is being stuck by needles. It logically follows that it would be best to avoid administering drugs via the intramuscular route. Other options then include giving a medication by the oral, rectal, or transmucosal route. The most commonly sited classes of medications used for preoperative purposes are hypnotics, opiods, N-methyl-D-aspartate (NMDA) receptor antagonists, and alpha-2 agonists. As a general rule, most children under approximately 10 months of age do not require sedation preoperatively because they have yet to develop separation anxiety.